Delivering intermediate care pathways in Somerset

Developing a new model of intermediate care and embedding ‘home first’ thinking

January to December 2020

86%

Reduction in long term placements from hospital since introduction of intermediate care

22%

Increase in supported discharges onto D2A pathway

Reframing the problem

Task

Impact

What new opportunities to improve outcomes and save money did we identify?

IMPOWER was commissioned by Somerset County Council to carry out an operational review of hospital discharge pathways, with a view to understanding avoidable demand across the health, social care & community system. This has led to the development of an alternative delivery model covering all of intermediate care in the county – a renewed end-to-end reablement service encompassing bed based and home pathways. The sustainability of the model was predicated on building the capability of frontline, multidisciplinary discharge teams.

Following the design phase, the work transitioned to acute and community hospital settings to help build ownership of the model amongst ward staff, embed the principles and support decision making in the ward setting.

How did we approach the task and what did we do?

IMPOWER helped the council, CCG, hospital leaders, and clinical and professional leads to review existing policy, leading to the development of a new strategy to transform the intermediate care offer, building on pre-existing strengths.

Our team worked across the system to:

Evaluate (on a clinical and care-outcome basis) discharge effectiveness across Somerset
Support the mobilisation of new healthcare discharge services across the county, and project manage the initial response to Covid
Support incidence response to emergent operational issues
Develop standard operating procedures for discharge
Understand day-to-day barriers faced by frontline staff that impede optimised intermediate care pathways
Support delivery of transformation by embedding change teams in acute and community hospital wards
Support the acute hospitals to operationalise the discharge lounges, help establish the new co-ordination hub and define a new hierarchy of bed use, building capability by embedding reflective practice.

What impact did our work have?

The emerging data about system behaviours in response to Covid is promising. Although in April 2020 a large number of interim beds were used to clear the hospitals in preparation for a surge, May showed a greater use of home pathways than prior to Covid.

In May 2020, around 50% of supported discharges were onto the D2A home pathway compared to 39% onto Pathway 1 between April and December 2019. The capacity on the home pathways (D2A and Rapid Response) has risen considerably as evidenced by the caseload, from a caseload of around 120 on 22 May to around 180 on 22 June, with only minor changes to length of stay.

Since the introduction of the intermediate care model in May 2020 there has been an 81% reduction in Long Term Care placements directly from hospital.

The ward work delivered several key impacts:

D2A patients had a 25% shorter length of stay than other pathways*
Only a third of D2A patients required an ongoing package of care, with only 1% of all D2A patients eventually requiring permanent placement*
Testing and validating hypotheses – identifying clear system building blocks for wider delivery
Identifying that small decisions at ward level, if replicated, will deliver significant system benefit in released bed days
IMPOWER’s on-ward presence pushed greater visibility of discharge conversations and decisions, encouraging holistic and transparent conversations
Proving the value of the intermediate care model, and identifying some clear steps and activities to successful embed this approach during 2021.

*Statistics approved by Mel Lock, director of social care at Somerset Council and Anna Littlewood, Deputy Director of Adult and health operations at Somerset Council